Chronic disease management in patients with intellectual disabilities: a matched study in Dutch general practice

BACKGROUND

Disease management programmes (DMPs) aim to deliver standardised, high- quality care to patients with chronic diseases. Although chronic diseases are common among people with intellectual disabilities (ID), this approach may be suboptimal for meeting their care needs.

AIM

To examine differences between patients with and without ID who have a chronic illness in DMP enrolment and disease monitoring in Dutch general practice.

DESIGN AND SETTING

Observational study utilising the Nivel Primary Care Database (2015-2018) comparing patients with ID and cardiovascular disease, diabetes mellitus, or chronic obstructive pulmonary disease (COPD) with matched (1:5) controls with these conditions but without ID.

METHOD

Using conditional logistic regression, enrolment in DMP per chronic disease was examined and differences tested between groups in the frequencies of consultations, medication prescriptions, and routine examinations.

RESULTS

A total of 2653 patients with chronic illness with ID were matched with 13 265 controls without ID. Patients with both diabetes mellitus and ID were more likely than controls to be enrolled in DMP (odds ratio [OR] = 1.44, 95% confidence interval [CI] = 1.27 to 1.64). Independent of DMP enrolment, patients with chronic illness with ID were more likely than controls to have frequent consultations. Patients with both diabetes mellitus and ID and patients with both COPD and ID who were not enrolled in DMPs had more medication prescriptions than non-enrolled patients with diabetes or COPD but without ID (OR = 1.46, 95% CI = 1.10 to 1.95; OR = 1.28, 95% CI = 0.99 to 1.66, respectively). Most patients with ID and their controls enrolled in DMPs received routine examinations at similar frequencies.

CONCLUSION

Although DMPs do not specifically address the needs of patients with both chronic illness and ID, these patients do not seem underserved in the management of chronic diseases in terms of consultation, medication, and tests.

Mechanisms of integrated care in Flanders: A bottom-up perspective

Background

For some time now, integrated care has been put forward to create a more demand-driven, patient-centred and cost-effective care system. Various conceptual frameworks have been developed to shed light on the complex concept. However, they lack insight into the mechanisms driving integrated care in practice. The aim of this paper is to gain insight into how integrated care is realised in practice.

Methods

Six cooperation projects in Flanders were compared on five integration mechanisms. A content analysis of secondary sources on each of the cases and semi-structured interviews with representatives of these cases was conducted. The data were analysed using comparison tables.

Results

Six cases representing five cooperation models in the Flemish health and social care were analysed for the presence of integrated care mechanisms. Six of the 22 mechanisms are present in all case examples. Half of the identified mechanisms concern the integration of professionals. Integrated care in these Flemish cases refers mainly to organising a case meeting, appointing a case manager and dividing the tasks between care professionals. Integration of support is less developed.

Conclusions

The bottom-up approach to study the practical implementation of mechanisms is a fruitful approach, since it brings into light the complex realities and practicalities of the mechanisms of integration and how they are shaped by local actors in local contexts. The approach shows how Flemish and Belgian policy makers are struggling to scaling up these integration models, whilst at the same time responding to local conditions and needs.

Care coordination for people with complex care needs in the U.S.: A policy analysis

The U.S. boomer population reaching the age of Medicare eligibility and the rising cost of healthcare are putting pressure on the sustainability of the federal Medicare fund. As a result people over 65 with complex care needs risk spending more out of pocket on their healthcare or becoming eligible for Medicaid as their personal resources are depleted. A number of recent initiatives have been developed to improve coordination of care for Medicare beneficiaries with complex care needs and to address the disjointed provision of care for patients who are eligible for Medicare and Medicaid. In order to improve care and reduce the financial burden on patients with complex care needs in the U.S., policy makers must take a system-wide approach, strengthening primary care systems, tackling those at highest risk, increasing care at home and in the community instead of institutions, ensuring better financial protection for patients, and offering healthcare providers financial incentives.